|
24 |
Role-play. PMB |
|
25 |
EMQ. Kangaroo care |
|
26 |
EMQ. Kell antibodies |
|
27 |
EMQ. Parvovirus |
|
28 |
EMQ. Ulipristal |
|
29 |
EMQ. ‘CAESAR’ trial |
24. Role-play. PMB.
Candidate’s
Instructions.
You
are an SpR in the “one-stop” PMB clinic. Mary Smith, 55 years old, has been
referred by her General Practitioner. She has had some bleeding since the
menopause.
Your
task is to take an appropriate history and advise her about the investigations
you feel are appropriate and why.
25. EMQ. Kangaroo care.
Question
1.
Which, if any, of the following are true in relation
to kangaroo care?
Option
list.
|
A. |
skin-to-skin contact between mother and baby is a key component |
|
B. |
rooming-in is a key component |
|
C. |
exclusive breastfeeding is a key component |
|
D. |
carrying the baby in a sling anterior to the maternal chest is a key
component |
|
E. |
carrying the baby in a sling on the mother’s back is a key component |
|
F. |
carrying the baby in a sling on the mother’s chest or back is a key
component |
|
G. |
carrying the baby in a sling with skin-to-skin contact with the mother
is a key component |
Question
2.
Which, if any,
of the following are proven benefits of Kc?
Option
list.
|
A. |
↓ neonatal mortality |
|
B. |
↓ neonatal morbidity |
|
C. |
↑ breastfeeding
rates |
|
D. |
↑ head circumference growth |
|
E. |
↓ hypothermia |
|
F. |
↑ mother-baby
bonding |
|
G. |
↓ necrotising
enterocolitis |
|
H. |
↓ neonatal
intra-ventricular haemorrhage |
|
I. |
↓ neonatal sepsis |
|
J. |
↑ neonatal
weight gain |
|
K. |
↓ postnatal
depression |
|
L. |
↑ psychomotor development
at 12 months |
26. EMQ. Kell antibodies.
Abbreviations.
∆OD450: spectrophotometric
measurement of deviation in optical density at wavelength 450 nm.
FMM: feto-maternal medicine.
HDFN: haemolytic disease of
the fetus and newborn.
MCAPSV: middle cerebral artery
peak systolic velocity.
RBC: red blood cell.
Scenario
1.
Which of the following alloantibodies is the most
common cause of significant HDFN?
Option list.
|
A |
anti-D |
|
B |
anti-C |
|
C |
anti-c |
|
D |
anti-e |
|
E |
Duffy:
Fya |
|
F |
Duffy:
Fyb |
|
G |
Kell |
|
H |
Kidd:
Jka |
|
I |
Kidd:
Jkb |
Scenario
2.
What is the 2nd. most common cause of
significant HDFN?
Scenario
3.
What is the 3rd. most common cause of significant
HDFN?
Scenario
4.
Which of the following is true in relation to the Kell
antigen?
Option list.
|
A |
it
is named after Mrs. Kelleher who was found to have antibodies to it in 1946 |
|
B |
it
is named after Gene Kelly, the American actor, dancer and singer as the research
group who found the antigen were big fans |
|
C |
there
are > 50 significant variants of the Kell antigen |
|
D |
Kell
antibodies are mainly IgA |
|
E |
Kell
antibodies are mainly IgM |
|
F |
none
of the above |
Scenario
5.
What proportion of the Caucasian population is K +ve?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
9% |
|
D |
15% |
|
E |
25% |
|
F |
33% |
|
G |
57% |
|
H |
none
of the above |
Scenario
6.
Can the Kell antigen be detected using cffDNA in
maternal serum. True / False.
Scenario
7.
Anti-K is thought to occur mainly as a result of
feto-maternal transfusion of Kell +ve
cells during pregnancy and delivery. True / False.
Scenario
8.
Kell HDFN resulting from transfusion of Kell +ve blood
is thought to produce more
severe HDFN than that resulting from feto-maternal transfusion. True /
False.
Scenario
9.
Which of the following statements is true in relation
to anti-Kell antibodies in a Kell-
negative mother with a Kell +ve pregnancy?
Option list.
|
A |
HDND
is mainly due to haemolysis of fetal RBC |
|
B |
HDND
is mainly due to haemolysis of fetal & neonatal RBC |
|
C |
HDND
is mainly due to haemolysis of neonatal RBC |
|
D |
HDND
is mainly due to sequestration of fetal RBC |
|
E |
HDND
is mainly due to sequestration of fetal & neonatal RBC |
|
F |
HDND
is mainly due to sequestration of neonatal RBC |
|
G |
HDND
is mainly due to suppression of fetal erythroid progenitor cells |
|
H |
HDND
is mainly due to suppression of neonatal erythroid progenitor cells |
|
I |
none
of the above |
Scenario
10. Which of the
following statements is true in relation to antenatal detection of HDFN
due to anti-K antibodies?
Option list.
|
A |
the
threshold for significant HDFN is a titre of 1 in 4 |
|
B |
the
threshold for significant HDFN is a titre of 1 in 8 |
|
C |
the
threshold for significant HDFN is a titre of 1 in 16 |
|
D |
the
threshold for significant HDFN is a titre of 1 in 32 |
|
E |
the
threshold for significant HDFN is a titre of 1 in 64 |
|
F |
the
threshold for significant HDFN is a titre of 1 in 128 |
|
G |
the
threshold for significant HDFN is a titre of 1 in 256 |
|
H |
none
of the above |
Scenario
11. Which of the
following statements is true in relation to antenatal detection of HDFN
due to anti-K antibodies?
Option list.
|
A |
the
threshold for significant HDFN is a level > 2 iu/L. |
|
B |
the
threshold for significant HDFN is a level > 4 iu/L. |
|
C |
the
threshold for significant HDFN is a level > 7.5 iu/L. |
|
D |
the
threshold for significant HDFN is a level > 10 iu/L. |
|
E |
the
threshold for significant HDFN is a level > 15 iu/L. |
|
F |
the
threshold for significant HDFN is a level > 25 iu/L. |
|
G |
the
threshold for significant HDFN is any level if anti-E is also present. |
|
H |
none
of the above |
Scenario
12. Which, if any, of
the following statements are true in relation to referral to a FMM
expert when Kell antibodies are detected?
Option list.
|
A |
the
threshold for referral is a level of anti-K > 2 iu/L. |
|
B |
the
threshold for referral is a level of anti-K > 4 iu/L. |
|
C |
the
threshold for referral is a level of anti-K > 7.5 iu/L. |
|
D |
the
threshold for referral is a level of anti-K > 10 iu/L. |
|
E |
the
threshold for referral is a level of anti-K > 15 iu/L. |
|
F |
the
threshold for referral is a level of anti-K > 25 iu/L. |
|
G |
the
threshold for referral is any level of anti-K. |
|
H |
the
threshold for referral is any level of anti-K if anti-E is also present. |
|
I |
none
of the above |
Scenario
13. Which of the
following statements is true in relation to the threshold for antenatal
diagnosis of significant HDFN due to anti-K when using measurement of MCAPSV?
Option list.
|
A |
MoM
> 1.25 |
|
B |
MoM
> 1.50 |
|
C |
MoM
> 1.75 |
|
D |
MoM
> 2.00 |
|
E |
MoM
> 2.50 |
|
F |
MoM
> 3.00 |
|
G |
none
of the above |
Scenario
14. Which of the
following statements is true in relation to the threshold for antenatal
diagnosis of significant HDFN due to anti-K when using measurement of
∆OD450?
Option list.
|
A |
MoM
> 1.25 |
|
B |
MoM
> 1.50 |
|
C |
MoM
> 1.75 |
|
D |
MoM
> 2.00 |
|
E |
MoM
> 2.50 |
|
F |
MoM
> 3.00 |
|
G |
none
of the above |
Scenario
15. Which, if any, of
the following statements are true in relation to the numbers of
reticulocytes in cord blood in moderate to severe HDFN due to anti-K
antibodies?
Option list.
|
A |
the
numbers are decreased |
|
B |
the
numbers are increased |
|
C |
the
numbers are normal |
|
D |
none
of the above |
Scenario
16. Which, if any, of
the following statements are true in relation to the numbers of
erythroblasts in cord blood in moderate to severe HDFN due to anti-K antibodies?
Option list.
|
A |
the
numbers are decreased |
|
B |
the
numbers are increased |
|
C |
the
numbers are normal |
|
D |
none
of the above |
Scenario
17. Which, if any, of
the following statements are true in relation to the level of bilirubin
in cord blood in moderate to severe HDFN due to anti-K antibodies?
Option list.
|
A |
it
is decreased |
|
B |
it
is increased |
|
C |
it
is greatly increased |
|
D |
none
of the above |
Scenario
18. Which, if any, of
the following are true in relation to King Henry VIII and Kell?
Option list.
|
A |
Kell
may have been the cause of his subfertility |
|
B |
He
may have had the McLeod syndrome |
|
C |
He
may have inherited the Kell antigen from Jacquetta Woodville |
|
D |
The
Kell antigen may have explained his passion for jousting |
|
E |
The
Kell antigen may have explained his passion for extramarital dalliance |
The TOG questions
for the Gajjar article can be found here.
They are open
access, which allows me to reproduce them.
Regarding Kell
alloimmunisation in pregnancy,
1 the amniotic fluid bilirubin level
correlates well with the degree of fetal anaemia. True / False
2 previous obstetric history does not
reliably predict outcome. True / False
3 the incidence in the obstetric population
is approximately 1–2 per 1000. True / False
4 prophylaxis is available. True / False
5 the relationship between fetal middle
cerebral artery peak systolic velocity (MCA-PSV) and haemoglobin concentration
is poor. True / False
6 anti-Kell antibodies cause fetal anaemia
via the suppression of erythropoiesis rather than red cell destruction. True / False
With regard to
maternal anti-Kell antibody screening,
7 if the father of the fetus is Kell antigen positive, the fetus
is likely to be affected with severe HDFN. True / False
8 where the father is heterozygous for Kell, there is a 50% chance
of the fetus carrying the Kell antigen on its fetal red cells. True / False
9 anti-Kell antibodies stimulated by transfusion are known to
affect the fetus to the same degree as those stimulated from a previous
pregnancy. True / False
Transfusion seems
to produce less severe disease.
10 where the critical titre of anti-Kell antibodies has been reached
in the maternal serum, amniocentesis for spectral analysis of amniotic fluid is
a reliable means of establishing the degree and severity of fetal anaemia. True / False
27. EMQ. Parvovirus.
Abbreviations.
PvB19: parvovirus B19
PvIgG: parvovirus B19 IgG
PvIgM: parvovirus B19 IgM
Option list.
There are no option lists apart from the last few questions. Make up your
own answers! In the exam it is best if you decide the answer without reference
to the option list and then identify it on the list.
Scenario
1.
What type of virus is parvovirus?
Scenario
2.
Is the title B19 something to do with the American B19 bomber, its potentially
devastating bomb load and the comparably devastating consequences of the
parvovirus on human erythroid cell precursors?
Scenario
3.
PVB19 in the UK occurs in mini-epidemics at 3 to 4-year intervals,
usually during the summer.
Scenario
4.
Which animal acts as the main reservoir for infection?
Scenario 5.
What is the approximate incidence of maternal parvovirus infection in
the UK?
Scenario
6.
What percentage of UK adults are immune to parvovirus infection?
Scenario
7.
What names are given to acute infection in the human?
Scenario
8.
What is the incubation period for parvovirus infection?
Scenario
9.
What is the duration of infectivity for parvovirus infection?
Scenario
10.
What are the usual symptoms of parvovirus infection in the adult?
Scenario
11.
What is the incidence of parvovirus infection in pregnancy?
Scenario
12.
How is recent infection diagnosed?
Scenario
13.
How long does PvIgM persist and why is this important?
Scenario
14.
What is the rate of vertical transmission of parvovirus infection?
Scenario
15.
Are women with parvovirus infection who are asymptomatic less likely to
pass the virus to their fetuses?
Scenario
16.
To what degree is parvovirus infection teratogenic?
Scenario
17.
What proportion of pregnancies infected with parvovirus are lost?
Scenario
18.
What is the timescale for the onset of hydrops?
Scenario
19.
Laboratories are advised to retain bloods obtained at booking for at
least 2 years for possible future reference. True or false?
Scenario
20.
What ultrasound features would trigger consideration of cordocentesis?
Scenario
21.
Must suspected parvovirus infection be notified to the authorities?
Scenario
22.
Possible parvovirus infection does not need to be
investigated after 20 week’s gestation. True or false?
Scenario
23.
If serum is sent to the laboratory from a woman with a
rash in pregnancy for screening for rubella, the laboratory should
automatically test for parvovirus infection too?
Scenario
24.
A woman attends the pre-pregnancy counselling clinic as she is planning
her first pregnancy. She wants to know what screening for parvovirus is
recommended.
Scenario
25.
A pregnant woman has had a significant contact with a
child with PARV infection. She has had urgent tests for PvIgG and PvIgM. Both
results were -ve. Which of the options best fits the advice she should be
given?
Option list.
|
1 |
the tests show acute parvovirus infection |
|
2 |
the tests show chronic parvovirus infection |
|
3 |
the tests show that she has not had PARV infection and is susceptible
to it |
|
4 |
the tests show no evidence of PARV infection but she should have
repeat tests in 1 month |
|
5 |
the tests show old PARV infection and immunity |
|
6 |
the tests show recent PARV infection |
|
7 |
none of the above |
Scenario
26.
A pregnant woman has had a significant contact with a
child with PARV infection. She has had urgent tests for PvIgG and PvIgM. Both
results were +ve. Which of the options best fits the advice she should be
given?
Option list.
|
1 |
the tests show acute parvovirus infection |
|
2 |
the tests show chronic parvovirus infection |
|
3 |
the tests show that she has not had PARV infection and is susceptible
to it |
|
4 |
the tests show no evidence of PARV infection but she should have
repeat tests in 1 month |
|
5 |
the tests show old PARV infection and immunity |
|
6 |
the tests show recent PARV infection |
|
7 |
none of the above |
Scenario
27.
A pregnant woman has had a significant contact with a
child with PARV infection. She has had urgent tests for PvIgG and PvIgM. The
results were PvIgG +ve and PvIgM -ve. Which of the options best fits the advice
she should be given?
Option list.
|
1 |
the tests show acute parvovirus infection |
|
2 |
the tests show chronic parvovirus infection |
|
3 |
the tests show that she has not had PARV infection and is susceptible
to it |
|
4 |
the tests show no evidence of PARV infection but she should have
repeat tests in 1 month |
|
5 |
the tests show old PARV infection and immunity |
|
6 |
the tests show recent PARV infection |
|
7 |
none of the above |
Scenario
28.
A pregnant woman has had a significant contact with a
child with PARV infection. She has had urgent tests for PvIgG and PvIgM. The
results were PvIgG -ve and PvIgM +ve. Which of the options best fits the advice
she should be given?
Option list.
|
1 |
the tests show acute parvovirus infection |
|
2 |
the tests show chronic parvovirus infection |
|
3 |
the tests show that she has not had PARV infection and is susceptible
to it |
|
4 |
the tests show no evidence of PARV infection but she should have
repeat tests in 1 month |
|
5 |
the tests show old PARV infection and immunity |
|
6 |
the tests show recent PARV infection |
|
7 |
none of the above |
Scenario
29.
A pregnant woman has had a significant contact with a
child with PARV infection. What prophylaxis should be offered?
Option list.
|
1 |
acyclovir orally |
|
2 |
acyclovir i.m. |
|
3 |
acyclovir i.v. |
|
4 |
hand-washing and avoiding small children |
|
5 |
i.v. hyperimmune globulin |
|
6 |
PVV vaccine |
|
7 |
there is no proven prophylaxis |
28. EMQ. Ulipristal.
Abbreviations.
EC: emergency contraception
eMC: electronic
medicines compendium
CYP450: cytochrome P450
UPA ulipristal
acetate
Question 1.
What type of drug is ulipristal?
Question 2.
How does ulipristal prevent conception as an
emergency contraceptive?
Question 3.
How is ulipristal broken down / excreted?
Question 4.
What is the half-life of ulipristal?
Question 5.
Which drug (erythromycin, phenobarbitone,
valium) may prolong the half-life of
ulipristal?
Question 6.
Which drugs may reduce the half-life of
ulipristal? There is no option list. Just write down as many drugs as you can
think of that induce the CYP450 enzymes.
Question 7.
What is the main
use of ulipristal?
Question 8.
What is the dose
of ulipristal?
Question 9.
What time-scale
applies to the licensed use of ulipristal?
Question 10.
What contraceptive
advice is given to those using ulipristal?
Question 11.
What advice is
given to women who are breast-feeding?
Question 12.
Can treatment with
ulipristal be repeated within 1 month?
Question 13.
Which medical
conditions are contraindications to ullipristal use ? These are not on the
option list.
Question 14.
What is the
current situation re prescribing ulipristal? Write the key facts.
29. SBA. ‘CAESAR’ trial.
Abbreviations.
ECV: external
cephalic version.
SSI: surgical
site infection.
Question 1. What was the CAESAR trial? Which, if any, of the
following statements are true?
Statements
|
A |
a prospective, cohort study |
|
B |
a
randomised, controlled trial |
|
C |
a comparison of selected techniques used during
Caesarean section |
|
D |
a study of the risks of Caesarean section on maternal
request without medical grounds |
|
E |
a study of the outcomes of C section performed after
failed instrumental delivery |
Question 2. Where did the questions addressed by the trial come from?
Option list
|
A |
the RCOG
council |
|
B |
the RCOG exam committee |
|
C |
a survey of UK obstetricians asking what questions they
would like to have answered |
|
D |
Dr. Johnstone, Consultant Obstetrician, Falkirk |
|
E |
National Childbirth Trust |
Question 3. The questionnaire also asked about the
issues that the respondents would like to see addressed in a research
programme. What issues were include in the CAESER trial?
Statements
|
A |
outcome of C. section depending on aqueous versus
alcohol-based skin preparation |
|
B |
cord traction versus manual removal of the placenta |
|
C |
digital versus ‘swab on a holder’ exploration of the
uterine cavity to exclude RPOC |
|
D |
Joel-Cohen
compared with Pfannenstiel incision |
|
E |
elective C. section at 38 versus 39 weeks |
|
F |
elective C. section with staff wearing masks versus not
wearing masks |
|
G |
prophylactic antibiotics versus no prophylactic
antibiotics |
|
H |
pre-op vaginal antiseptic “painting” versus none |
|
I |
blunt v. sharp opening of the lower segment |
|
J |
manual versus forceps delivery of the fetal head in
cephalic presentations |
|
K |
single v double closure of the lower segment |
|
L |
closure v non-closure of parietal & pelvic
peritoneum |
|
M |
liberal v restricted use of pelvic drains |
|
N |
glue v subcuticular suturing of the skin |
|
O |
none of the above |
Question 4. Which of the following statements is true of the
definition of the 1ry. outcome?
Option list
|
A |
use of
antibiotics for maternal infectious morbidity during the hospital stay |
|
B |
use of antibiotics for maternal infectious morbidity
during the 1st. six weeks |
|
C |
duration of postnatal hospital stay |
|
D |
abdominal and pelvic pain as measured on an analogue
scale at 6 weeks |
|
E |
none of the above. |
Question 5. Which, if any, of the following
describe the 2ry. outcomes? > 1 may
be correct.
Statements:
|
A |
additional
treatments to the abdominal wound |
|
B |
haematoma formation |
|
C |
pain |
|
D |
breast feeding at discharge |
|
E |
breast feeding at 6 weeks |
|
F |
unexpected maternal morbidity |
|
G |
postnatal depression at 6 weeks |
|
H |
puerperal psychosis |
Question 6. Which if any of the following statements are true of the
findings of the study?
Statements
|
A |
there
were no significant differences for any outcome |
|
B |
there was more endometritis after non-closure of the
pelvic peritoneum |
|
C |
there was more 2ry. bleeding after interrupted-suture
closure of the lower segment |
|
D |
there was more evidence of pelvic infection with
liberal use of pelvic drains |
|
E |
none of the above. |
Question 7. When does the WHO recommend that
prophylactic antibiotics be given at C section.
Option list
|
A |
4 hours before the incision |
|
B |
2 hours before the incision |
|
C |
1 hour before the incision |
|
D |
with the incision |
|
E |
just before the
incision |
Question 8. What did the paper by Sommerstein et al of December 2020
add to the debate on timing of administration of prophylactic antibiotics at C
section?
Option list.
|
A |
prophylactic antibiotics are most
effective if given 1 hour before incision |
|
B |
prophylactic antibiotics are most effective
if given ½ hour before incision |
|
C |
prophylactic antibiotics are most
effective if given at the time of incision |
|
D |
prophylactic antibiotics are less
effective if given after cord clamping |
|
E |
prophylactic antibiotics are equally
effective if given after cord clamping |
|
F |
prophylactic antibiotics are most
effective if given at incision and continued for 48 hours |
|
G |
none of the above |
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